1.
A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation
Photosensitivity is a side effect of Prolixin and a vacation in the Bahamas (with its tropical island climate) increases the client's chance of experiencing this side effect. He should be instructed to avoid direct sun (A) and wear sunscreen. (B, C, and D
2.
A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature,
The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety related to (A) should be addressed after giving the client Ativan for el
3.
The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit?
A) Monitor appe
The most important reason for closely observing a depressed client immediately after admission is to maintain safety (B), since suicide is a risk with depression. (A, C, and D) are all important interventions, but safety is the priority.
Correct Answer(s)
4.
A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response is most appropriate for the
(A) is the best choice cited. The nurse does not argue with the client nor demand that she eat, but offers support by agreeing to "be there if needed", e.g., to warm the food. (B and C) are arguing with the client's delusions, and (B) asks "why" which is
5.
A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take?
A) Notify the healthcare provider immediately and prepare for administration of an antidote.
B) No
Early side effects of lithium carbonate (occurring with serum lithium levels below 2.0 mEq per liter) generally follow a progressive pattern beginning with diarrhea, vomiting, drowsiness, and muscular weakness. At higher levels, ataxia, tinnitus, blurred
6.
The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the teenager, what information is most important for the nurse t
Knowledge of all substances taken (C) will guide further treatment, such as administration of antagonists, so obtaining this information has the highest priority. (A and B) are also valuable in planning treatment. (D) is not appropriate during the acute m
7.
The wife of a male client recently diagnosed with schizophrenia asks the nurse, "What exactly is schizophrenia? Is my husband all right?" Which response is best for the nurse to provide to this family member?
A) It sounds like you're worried about your
The nurse should answer the client's question with factual information and explain that schizophrenia is a chemical imbalance in the brain (B). (A) is a therapeutic response but does not answer the question, and may be an appropriate response after the nu
8.
The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medicatio
The most important nursing problem is medication management (C) because compliance with the medication regimen will help prevent hospitalization. The client is also exhibiting signs of (A, B, and C); however, these problems do not have the priority of med
9.
At a support meeting of parents of a teenager with polysubstance dependency, a parent states, "Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide." The nurse's response should be based on which info
The priority is to teach the parents that their son will need monitoring and support during withdrawal (D) to ensure that he does not attempt suicide. Although (A and C) are true, they are not as relevant to the parent's expressed concern. There is no inf
10.
The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, "Yes, my love, I'll do it." When the nurse questions the client about her comment she states, "The news commentator is my lover and he
It is imperative that the nurse determine what the client believes she heard (A). The idea of reference may be to hurt herself or someone else, and the main function of a psychiatric nurse is to maintain safety. (B) is acceptable, but it is best to determ
11.
At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you're the le
Anxiety over participation in a group and testing of the leader characteristically occur in the initial phase of group dynamics. (B) provides information and focuses the group back to defining its function. (A) is manipulative bargaining. Although (C) pro
12.
The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing
The best nursing diagnosis is (A) because the client is unable to acknowledge the move to a boarding home. (B, C, and D) are potential nursing diagnoses, but denial is most important because it is a defense mechanism that keeps the client from dealing wit
13.
Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?
A) Hamburger, French fries
Only (D) contains no tyramine. Tyramine in foods interacts with MAOI in the body causing a hypertensive crisis which is life-threatening, and Parnate is classified as an MAOI antidepressant. Some items in (A, B, and C) contain tyramine and would not be pe
14.
An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide?
A) Orient the client to the time
Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of "offering self" and "talking to the feelings" to provide reassurance (B). Clients with advanced dementia have permanent physiologi
15.
The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam?
A) Acute psychiatric illnesses impair intelligence.
B) Intelligence is influenced by social and cultural beliefs.
C) Poo
Social and cultural beliefs (B) have significant impact on intelligence. Chronic psychiatric illness may impair intelligence (A), especially if it remains untreated. Limited concentration does not suggest limited intelligence (C). Difficulties with abstra
16.
The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.)
A) Permit rest periods as needed.
B) Speaking slowly and simply.
C) Place the client on suicide pr
(A, B, D, E, and F) should be included in this client's plan of care because these measures promote the client's comfort and well-being. Neurovegetative symptoms accompany the mood disorder of depression and include physiological disruptions, such as anor
17.
An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the nurse to provide?
A) Anywhere you want to stand a
It is common for those with Alzheimer's disease to use the wrong words. Redirecting the client (using an accepting non-judgmental dialogue) to a safer place and familiar activities (C) is most helpful because clients experience short-term memory loss. (A)
18.
Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate). What is m
Alcohol enhances the EPS side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of the Prolixin Decanoate IM is 2 to 4 weeks. That means the side effects of drinking alcohol are far more severe when the client drinks alco
19.
An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?
A) You are in the hospital
Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others (C). Delusions are often well-fixed, and though (A) reinforces reality
20.
A male client with schizophrenia tells the nurse that the voices he hears are saying, "You must kill yourself." To assist the client in coping with these thoughts, which response is best for the nurse to provide?
A) Tell yourself that the voices are u
The nurse should teach the client to use self-talk to disprove the voices (A). Although (B) may be helpful, the client's concrete thinking may make it difficult to understand this suggestion. Clients with schizophrenia have difficulty initiating interacti
21.
A 30-year-old sales manager tells the nurse, "I am thinking about a job change. I don't feel like I am living up to my potential." Which of Maslow's developmental stages is the sales manager attempting to achieve?
A) Self-Actualization.
B) Loving and
Self-actualization is the highest level of Maslow's development stages, which is an attempt to fulfill one's full potential (C). (B) is identifying support systems. (C) is the first level of Maslow's developmental stages and is the foundation upon which h
22.
A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client
The case manager (B) is responsible for coordinating community services, and since this client has a dual diagnosis, this is the best person to describe available treatment options. (A) is unnecessary, unless the client experiences behaviors that threaten
23.
The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up?
A) Menstruation onset at age 9.
B) Contraceptive method includes condoms only.
C) Menstrual cycle occurs every 35 d
A "black-out" typically occurs after ingestion of alcohol beverages that the client has no recall of the experiences or one's behavior and is indicative of high blood alcohol levels, but the client's experience of a "black-out" after one drink (D) is susp
24.
On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which class of disorder?
A) Neurotic.
B) Personality.
C) Anxiety.
D) Psychotic.
Delusions are false beliefs associated with psychotic behavior, and psychotic persons are not in touch with reality (D). (A, B, and C) are mental health disorders which are not associated with a break in reality, nor with hallucinations (false sensations
25.
A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verball
The client is trying to engage the nurse in a dispute. Ignoring the behavior (D) provides no reinforcement for the inappropriate behavior. (A) is not necessary unless the client becomes a physical threat to the nurse. (B) would be inappropriate, because i
26.
The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client's
The client is demonstrating symptoms of schizophrenia (C), such as disorganized speech that may include word salad (communication that includes both real and imaginary words in no logical order), incoherent speech, and clanging (rhyming). Dementia (A) is
27.
A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider?
A) Decreased thyroid stimulatin
Hyperthyroidism causes an increased level of serum thyroid hormones (T3 and T4), which inhibit the release of TSH (A), so the client's manic behavior may be related to an endocrine disorder. (B, C, and D) are abnormal findings that are commonly found in t
28.
A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take?
A) Encourage the client's participation in unit activities by asking her to pa
Anorexics gain pleasure from providing others with food and watching them eat. Such behaviors reinforce their perception of self-control. These clients should not be allowed to plan or prepare food for unit activities and their desires to do so should be
29.
A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client?
A) Let me call
It is best for the nurse to call the healthcare provider (A) because clients have the right to information about their treatment. Suggesting that the healthcare provider will be available the following day (B) does not provide immediate reassurance to the
30.
A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend. After acknowledging the client's fear and anxiety, ho
A victim of date rape or acquaintance rape is less prone to recognize what is happening because the incident usually involves persons who know each other and the dynamics are different than rape by a stranger. (C) provides confrontation for the client's d
31.
A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response?
A) Can your case manager take you to your
The best response is to explore ways for the client to cope with anxiety (D). The nurse should encourage problem-solving rather than dependence on the case manager (A) for transportation. Strategies for coping with anxiety should be encouraged before sugg
32.
The nurse is leading a "current events group" with chronic psychiatric clients. One group member states, "Saddam Hussein was my nurse during my last hospitalization. He was a very mean nurse and wasn't nice to me." Which response is best for the nurse
(D) presents the reality of the situation (the individual is not nice) in relation to American culture. The fact that Saddam Hussein is not a nurse should be addressed on an individual basis. Since this is group therapy, the nurse would be illustrating th
33.
Which statement about contemporary mental health nursing practice is accurate?
A) There is one approved theoretical framework for psychiatric nursing practice.
B) Psychiatric nursing has yet to be recognized as a core mental health discipline.
C) Cont
Mental health nursing is not only concerned with one-on-one interactions. Psychiatric stressors can impact and be reflected in the overall direction, activities, and responses involving families, groups, and entire communities (D). (A, B, and C) are incor
34.
A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to
The client is in Erikson's "Generativity vs. Stagnation" stage (age 24 to 45), and meeting the task includes maintaining intimate relationships and moving toward developing a family (B). (A) occurs in young adulthood (age 18 to 25), (C) occurs in maturity
35.
A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, "No, it's not MY fault. You can't blame me. I didn't kill him, you did." What action
Further assessment is indicated (C). The nurse should obtain information about what the client believes the voices are telling him--they may be telling him to kill the nurse! (A) is telling the client how he feels (fearful). The nurse should leave communi
36.
A 27-year-old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care?
A) Schedule her to attend va
Clients in the manic phase of a bipolar disorder require decreased stimuli and a structured environment (D). Plan noncompetitive activities that can be carried out alone. (A) is contraindicated; stimuli should be reduced as much as possible. Impulsive dec
37.
A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?
A) Did you really believe you were Jesus Christ?
B) I think you're getting well.
C) O
(C) offers support by assuring the client that others have suffered as he has (also the principle on which Alcoholics Anonymous acts). (A) is belittling. (B) is making an inappropriate judgment. You may have narrowed your choices to (C and D). However, yo
38.
The nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic?
A) Loss of independence.
Middle adulthood is characterized by self-reflection, understanding, and acceptance (B), and generativity or guidance of children. (A and C) are maladaptive behaviors in middle adulthood. Although middle-aged adults may delay or re-establish intimate rela
39.
A 25-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse
(D) is the best response because it offers support without judgment or demands. (A) is arguing with the client's delusion. (B) is offering false reassurance. (C) is a violation of therapeutic communication in that the nurse is telling the client how she f
40.
A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan? (Select all that apply.)
Correct choices are (A, B, D, and E). To promote client understanding and compliance, the teaching plan should include explanations about the origin and treatment options of OCD symptomology. Compulsions are behaviors that help relieve anxiety (A), which
41.
A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of
The most important intervention is to reassess the client's mental status (D) and to take further action based on the findings of this assessment. Attempting to reassure the client (A) is in effect arguing with the client's delusions and could escalate an
42.
On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-fours after admission, the nurse notes that the client is withdrawn and isolated. It is best for t
Peer interaction in a group activity (B) will help to prevent social isolation and withdrawal. (A, C, and D) are activities that can be accomplished alone, without peer interaction.
Correct Answer(s): B
43.
A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, "Because he made me mad!" Which goal is best for the
Those with bipolar disorder often exhibit poor impulse control, and the most important goal for this client at this time is to learn to control impulsive behavior (B) so that he can avert the social consequences related to such behaviors. (A, C, and D) ar
44.
A 35-year-old male client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal his clothing. Which action should the nurse implement?
A) Encourage the client to actively participate in assigne
Diverting the client's attention from paranoid ideation and encouraging him to complete assignments can be helpful in assisting him to develop a positive self-image (A). The client's problem is not security, and (B) actually supports his paranoid ideation
45.
A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten
The nurse should initiate a referral based on anxiety levels (B) and feelings of nervousness that interfere with sleep, appetite, and the inability to solve problems. The client does not report symptoms of (A) or evidence of (C). There is not enough infor
46.
A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won'
Projection is attributing one's own thoughts, impulses, or behaviors onto another--it is the mother who is probably harming the child and she is attributing her actions to the nurse (C). The mother may be immature, but (A) is not the best description of h
47.
An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client?
A) Plan an outing within the first week of admission.
B) Distract her whenever she e
The process of gradual desensitization by controlled exposure to the situation which is feared (D), is the treatment of choice in phobic reactions. (A and C) are far too aggressive for the initial treatment period and could even be considered hostile. (B)
48.
The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions?
A)
(D) provides the most validation. The parent's explanation (subjective data) is incompatible with the objective data (small round burns on the legs and trunk). (A) provides only subjective data, and the child's explanation could be influenced by factors s
49.
The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen.
St. John's Wort, an herbal preparation, is an alternative (nonconventional) therapy for depression, but it may adversely interact with medications used to treat HIV infection (C). The nurse's top priority upon admission is to determine if the client has b
50.
A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms?
A) Perphenazine (Trilafon).
B) Diphenhydramine (Bena
Librium (C), an antianxiety drug, as well as other benzodiazepines, are used in titrated doses to reduce the severity of abrupt benzodiazepine withdrawal. (A) is an antipsychotic agent. (B) is an antihistamine and antianxiety drug. (D) is an MAO inhibitor
51.
A 35-year-old male client on the psychiatric ward of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his
A) early childhood experiences involving authority is
Psychotic clients have difficulty with trust and have low self-esteem (C). Nursing care should be directed at building trust and promoting positive self-esteem. Activities with limited concentration and no competition should be encouraged in order to buil
52.
The nurse plans to help an 18-year-old female mentally retarded client ambulate the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, "Get out of
(D) provides a "cooling off" period, is firm, direct, non-threatening, and avoids arguing with the client. (A) is avoiding responsibility by referring to the healthcare provider. (B) is trying to reason with a mentally retarded client and is threatening t
53.
A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?
A) Grandiose ideation.
B) Self-destructive thoughts.
C) Suspiciousness of others.
D) A negative view of self and the futur
Negative self-image and feelings of hopelessness about the future (D) are specific indicators for depression. (A and/or C) occurs with paranoia or paranoid ideation. (B) may be seen in depressed clients, but are not always present, so (D) is a better answ
54.
A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that
Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness, which is the definition of a dissociative disorder (A). (B) is characterized by persistent, recurrent intrusive thoughts or urges (obs
55.
A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first?
A) Do you have problems with hallucinations?
B) Are you ever alone when you hear the voices?
C) Has any
Determining if the client is alone when she hears voices (B) will assist in differentiating between hallucinations and hearing loss; this is especially important in the aging population. If the client is experiencing hallucinations, the voices will be rea
56.
When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), it is most important for the nurse to include which instruction?
A) It may take 3 to 4 weeks to achieve therapeutic effects.
B)
Lithium's effectiveness is influenced by salt intake (B). Too much salt causes more lithium to be excreted, thereby decreasing the effectiveness of the drug. Too little salt causes less lithium to be excreted, potentially resulting in toxicity. (A, C, and
57.
Over a period of several weeks, one male participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to tak
After several weeks, the group is in the working phase and the group members should be allowed to determine the direction of the group. The nurse should ignore the client's comments and allow the group to handle the situation (C). A good leader should not
58.
The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing intervention bests helps this client deal with his depression?
A) Ensure that the client's day is filled with group activities.
B) Assist the client in e
Depression is associated with feelings of shame, anger, and guilt. Exploring such feelings is an important nursing intervention for the depressed client (B). If the client's day is filled with group activities (A) he might not have the opportunity to expl
59.
The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which complaint related to administration of this drug should the nurse expect this client to make?
A) My mouth feels like cotton.
B) That stuff give
A dry mouth (A) is an anticholinergic effect that is an expected side effect of MAO inhibitors such as phenelzine sulfate (Nardil). (B, C, and D) are not expected side effects of this medication.
Correct Answer(s): A
60.
A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which a
Because the client is unable to follow instructions, emetic therapy would be very difficult to implement and gastric lavage would be necessary (C). (A and B) should be considered in determining the course of treatment, but they are not the basis for deter
61.
A 46-year-old female client has been on antipsychotic neuroleptics for the past three days. She has had a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she
These symptoms are descriptive of neuroleptic malignant syndrome (NMS) which is an extremely serious/life threatening reaction to neuroleptic drugs (B). The major symptoms of this syndrome are fever, rigidity, autonomic instability, and encephalopathy. Re
62.
A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying poison him. What intervention should the nurse include in this client's plan of care?
A) Remind the client that his suspicions are not true.
B) Ask one nur
A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationship with one nurse (B) is likely to be therapeutic for this client. (A) is argumentative. Stress increases anxiety, and anxiety increases paranoid ideation;
63.
The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?
A) Dizziness when standing.
B) Shuffling gait and hand tremors.
C) Urinary retention.
D) Fever of 102� F.
A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. (A, B, and C) are all adverse effects of Haldol wh
64.
Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?
A) Administer a prescribed P
Initially, the nurse should allow time for the ritual (C) to prevent anxiety. (A) may help reduce the client's anxiety, but will not prevent ritualistic behavior resulting from the client's ineffective coping ability. (B) is a long-term goal of individual
65.
A 72-year-old female client is admitted to the psychiatric unit with a diagnosis of major depression. Which statement by the client should be of greatest concern to the nurse and require further assessment?
A) I will die if my cat dies.
B) I don't fee
Sometimes a client will use an analogy to describe themselves, and (A) would be an indication for conducting a suicide assessment. (B) could have a variety of etiologies, and while further assessment is indicated, this statement does not indicate potentia
66.
The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge?
A) Crickets are a good source of protein.
B) I have not
The most frequent cause of increased symptoms in psychotic clients is non-compliance with the medication regimen. If clients believe that "God alone" is going to heal them (C), then they may discontinue their medication, so (C) would pose the greatest thr
67.
A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?
A) The nurse should ob
It is the nurse's legal responsibility to report all suspected cases of child abuse. Notifying the charge nurse starts the legal reporting process (C).
Correct Answer(s): C
68.
Physical examination of a 6-year-old reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by t
(B) seeks more information using an open ended, non-threatening statement. (A) could be appropriate, but it is not the best answer because the nurse is being somewhat sarcastic and is also avoiding the situation by referring it to the healthcare provider
69.
A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?
A) Client will not demonstrate cross-addiction.
B) Co-dependent behaviors will be
Substitution therapy with another CNS depressant is intended to decrease the excessive CNS stimulation that can occur during benzodiazepine withdrawal (C). (A, B, and D) are all appropriate outcome statements for the client described, but do not have the
70.
A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. The nurse knows that the client is using which defense mechanism?
A) Sublimation.
B) Identificatio
Identification (B) is an attempt to be like someone or emulate the personality traits of another. (A) is substituting an unacceptable feeling for one that is more socially acceptable. (C) is incorporating the values or qualities of an admired person or gr
71.
A client with bipolar disorder on the mental health unit becomes loud, and shouts at one of the nurses, "You fat tub of lard! Get something done around here!" What is the best initial action for the nurse to take?
A) Have the orderly escort the client
Distracting the client, or redirecting his energy (C), prevents further escalation of the inappropriate behavior. (A) could result in escalating the abuse and unnecessarily involve another staff member in the abusive situation. (B) is a threat and is usin
72.
A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make?
A) How can I help?
B) Things probably aren't as bad as they seem right now.
C) Let'
Offering self shows empathy and caring (A), and is the best of the choices provided. Combining the first part of (D) with (A) would be the best response, but this is not a fill-in-the-blank or an essay test! Choose the best of those choices provided and m
73.
A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change and the nurse formulates the diagnosis, "Confusio
The critical care environment confronts clients with an environment which provides stressors heightened by treatment modalities that may prove to be lifesaving. These stressors can result in isolation and confusion. The best intervention is to provide the
74.
A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is most characteristic of a client with schizophrenia?
A) Mood swings.
B) Extreme sadness.
C) Manipulativ
Disinterest, and diminished or lack of facial expression is characteristic of schizophrenia and is referred to as a flat affect (D). (A) is associated with bipolar disorder. (B) is associated with depression. (C) is usually associated with personality dis
75.
A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She
Agoraphobia (C) is the fear of crowds or being in an open place. (A) is the fear of being in closed places. (B) is the fear of high places. Remember, a phobia is an unrealistic fear which is associated with severe anxiety. (D) consists of the development